Asthma Review Form

This field is for validation purposes and should be left unchanged.

Full Name(Required)

Date of Birth(Required)

Email(Required)

Phone Number(Required)

Please complete the following questions to allow your health care professional to assess your asthma.

How often does your asthma cause symptoms during the day?(Required)

Never

1 to 2 times per month

1 to 2 times per week

Most days

How often does your asthma cause symptoms at night?(Required)

Never

1 to 2 times per month

1 to 2 times per week

Most days

How often does your asthma limit your activities?(Required)

Never

1 to 2 times per month

1 to 2 times per week

Most days

How many asthma exacerbations (attacked) have you had in the past year?(Required)

How many times have you attended Accident and Emergency Department since your last asthma review?(Required)

Inhaler Technique

Please select the types of inhalers that you use(Required)

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler(Required)

Lifestyle - Alcohol

How often do you have a drink containing alcohol?(Required)

Never

Monthly or less

2-4 times a month

2-3 times a week

4 times or more a week

How many units of alcohol do you drink on a typical day drinking?(Required)

1 - 2

3 - 4

5 - 6

7 - 9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Lifestyle - Smoking

Do you smoke?(Required)

Never smoked

Ex-smoker

Trivial smoker (less than 1 cigarette per day)

Light Smoker (1-9 cigarettes per day)

Moderate smoker (10-19 cigarettes per day)

Heavy smoker (20-39 cigarettes per day)

Very heavy smoker (40 or more cigarettes per day)

Do you use an e-cigarette?(Required)

Ex-user

Yes

Would you like help to quit smoking?(Required)

Yes

For further information, please see: nhs.uk/quit-smoking

Asthma Control Test Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?(Required)

All of the time

Most of the time

Some of the time

A little of the time

None of the time

How often have you had shortness of breath?(Required)

More than once a day

Once a day

3-6 times a week

1-2 times a week

Not at all

How often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?(Required)

4 or more times a week

2-3 nights a week

Once a week

Once or twice

Not at all

How often have you used your reliever inhaler (usually blue)?(Required)

3 or more times a day

1-2 times a day

2-3 times a week

Once a week or less

Not at all

How would you rate your asthma control?(Required)

Not controlled

Poorly controlled

Somewhat controlled

Well controlled

Completely controlled

Your Calculated Asthma score(Required)

Your score is less than 20.

Your asthma may not have been controlled during the past 4 weeks.

Your doctor or nurse can recommend an asthma action plan to help improve your asthma control.

Your score is between 20 and 24.

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

However, if you are experiencing symptoms your doctor or nurse may be able to help you.

Your score is 25, well done!

Your asthma appears to have been under control over the last 4 weeks.

However, if you are experiencing any problems with your asthma, you should see your doctor or nurse.

Further Questions

I have the following information, questions or concerns that I would like to raise with my Asthma Nurse or Doctor

Appointments

Prescriptions

Test Results

Sick Notes

Update your Details

Opening Times - Thurso

Monday08:30am to 05:30pm
Tuesday08:30am to 05:30pm
Wednesday08:30am to 05:30pm
Thursday08:30am to 05:30pm
Friday08:30am to 05:30pm
SaturdayCLOSED
SundayCLOSED

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Thurso & Halkirk Medical Practice

Asthma Review Form

Please complete the following questions to allow your health care professional to assess your asthma.

Inhaler Technique

Lifestyle - Alcohol

Lifestyle - Smoking

Asthma Control Test Score

Further Questions

Opening Times - Thurso

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Body Parts

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